Greg Mankiw has a brilliant piece in the New York Times urging America not to take scary health care statistics at face value.
Copyright © 2009 by The Atlantic Monthly Group. All rights reserved.
Copyright © 2009 by The Atlantic Monthly Group. All rights reserved.
Setting aside a critique of Mankiw's evaluation of the numbers (the fact that ten million of the uninsured are illegal immigrants makes reform more pressing, not less), this kind of thing is irrelevent. It is immoral for a person to lack a certain minimum level of health care because of his or her economic status. If the number of people so lacking is 1 or 100 million, the moral imperative to fix that problem remains the same.
As time goes by, it is increasingly irrelevant to state the percentage of people who (supposedly) have health insurance. More and more employer-provided policies have coverage that is so inadequate as to be fraudulent. This miserable coverage is, in my experience, one reason why people who could have insurance through their employers, decline to purchase it. A typical plan for a low-wage worker would involve $100 per month in premiums for the worker, and would cover a few doctor visits, and a few days of hospitalization. Many young people, not surprisingly, say to themselves that they can cover the cost of a doctor visit and a prescription or two, and that what they really need is catastrophic insurance. If what's offered at work is the reverse of catastrophic, why would we expect them to purchase it?
Freddie,
Accepting for the moment that it is a moral imperative, what did Mankiw write? He wrote that the extent of the problem matters in how you go about fixing it, and how you affect the population that already has insurance. If it is true that you have to actually supply insurance for 47 million people, then your solution might take one form, but if the number is only, let us say, 10 million, then your solution might take some other form entirely.
Also, are you supporting government supplied health care for illegal immigrants?
Apart from providing the number of illegal immigrants without medical insurance, Mankiw's article was maddeningly vague. He talked about people who are uninsured by choice, but didn't give numbers, and he used the usual libertarian trick of conflating the plans proposed by the Democratic presidential contenders with more statist health systems. Is this the best that Megan's side can offer?
Freddie,
Who is lacking the "minimum level" of health care? I was under the impressions emergency rooms have to care for everyone.
Also, are you supporting government supplied health care for illegal immigrants?
Yancey, note that Mankiw carefully said "insurance" for illegal immigrants. We already provide emergency medical care for illegal immigrants, despite occasional efforts to cut them off, and I don't see that changing as long as people can show up to emergency rooms in desperate need of care.
Stan,
Where does Prof. Mankiw mention the Democratic presidential contenders?
Is nationalized health care going to be a deluxe model? And if so, is it really going to be cheaper than what most people get now? And is my employer really going to raise my salary by the amount of his current contribution and tax savings for my current insurance?
And Stan, most proponents of nationalized health care cite life expectancies and infant mortality rates without even mentioning these factors at all. At least Mankiw brings them up. Maybe now the pro-nationalized health care forces can actually address them since they are the ones proposing the change.
EI
If it is true that you have to actually supply insurance for 47 million people, then your solution might take one form, but if the number is only, let us say, 10 million, then your solution might take some other form entirely.
That argument would be compelling if there was anything approaching unanimity on the question of whether we should change at all, or make an effort to improve coverage at all. There isn't, particularly around here. I'm reacting in part to the implied argument "not that many people are actually uninsured, therefore we don't have a major problem, therefore there isn't a pressing need for major change." And, in my opinion, even if the number of people who lack coverage is smaller than advertised, the moral imperative to cover everyone still necessitates immediate change. In another sense, yes, you're right, of course, that the number of people who lack coverage is going to influence how we go about reforming how coverage is obtained. But let's not assume facts not in evidence about whether we all agree change is necessary or to what extent.
Also, are you supporting government supplied health care for illegal immigrants?
The government is already providing health care for illegal immigrants. It does so because they go to ERs for medical care when discomfort or risk of permanent damage or death forces them to. As has been demonstrated, this is an incredibly inefficient and wasteful way to deliver care to anyone. Treatment in the ER is expensive and clogs the ER system when the conditions aren't acutally immediately threatening. Those that are immediately threatening could have been treated with less expense or difficulty if treated preventatively in the past. Since illegals are already getting their health care de facto through public expenditure, let's see to it that we provide it more intelligently.
Who is lacking the "minimum level" of health care? I was under the impressions emergency rooms have to care for everyone.
In addition to being a terrible model for efficient or effective delivery of health care, the "just go to the ER" model does not meet my standard for an acceptable minimum level of care. Note that I use the "phrase minimum level of care" because if I say that no one's health care should be determined by their financial circumstances, libertarians will attack me for suggesting that rich people shouldn't be entitled to pay more for extra or special care above what we would consider appropriate.
More and more employer-provided policies have coverage that is so inadequate as to be fraudulent.
Indeed. The number of people who are considered fully covered statistically and yet are routinely denied care by their insurance or HMO is legion.
Freddie, if covering everyone is a moral imperative, shouldn't we be more concerned about people in the developing world who often totally lack access to health care than about people in this country who while they may not have the coverage that you desire do have some access to health care.
Freddie, if covering everyone is a moral imperative, shouldn't we be more concerned about people in the developing world who often totally lack access to health care than about people in this country who while they may not have the coverage that you desire do have some access to health care.
No more than we should be concerned about protecting their territorial integrity with our armies or supplying them food and water with our infrastructure or trash collection.... While I recognize a moral duty to anyone and I am in some senses an internationalist, the fact remains that a)nations exist and b)as a member of this democracy, my civic responsibility is to try to improve it, not other countries in the world.
Besides I've never been one for telescopic philanthropy.
Freddie the difference between me and you apparently is that regardless of the extent of the problem you believe that a moral imperative implies the government should require everyone to fall in line and go along with what plan of the day you subscribe too.
My issue with that is I don't believe we'll reach some future Utopia where suddently no further increased action is required of the govt. because we've vanquished all our moral imperatives, but instead we'll continue to grow and grow and grow govt. and make things gradually worse for us all.
This is really beginning to sound like religion. Moral impertive to reduce C02. Moral imperative to give everyone top notch access to cheap health care. Moral imperative to give everyone cable tv. Well we haven't gotten there yet.
Do you believe the only things a person should have to pay for are entertainment? Why is it out of the question that a person should have to pay for the health of themselves and their family? I can definitely see the tremendous benefits of offering every child a pony. After all think how much happier we'd all be if we grew up with ideal childhoods. We'd no doubt be better workers. But the issue is what it costs to do these schemes. Why do you insist on betting the farm that we can make America over in Sweden or Englands image?
Why can't you be satisfied with taking care of those who are unable to take care of themselves while requiring others who can take care of themselves to eventually do so if they've fallen on hard times.
We CAN'T do everything for everyone. Digging a bit deeper, we don't want to do everything for everyone.
But if I read you correctly, after the government has guarenteed us retirement, health care, housing, food, all we have left to do on our own is decide what movie we want to see or what restaurant to go to...
What if switching to nationalised healthcare or government provided insurance breaks the system and reduces the quality of health care for everyone? Wouldn't that be worse than the system we have now?
The issue at hand is not whether or not we have a problem. It is how big the problem really is and how should we solve it. (almost) No one disputes that we should avoid letting people die for lack of health care.
I'm okay with providing health care for illegal aliens. Let's restore them to health, then immediately deport them. Or make them pay it off. Giving free health care to illegal aliens (criminals) without consequence is the absolute wrong thing to do, even if it might be more economically efficient. (And I doubt it would be... such a system would just encourage more illegal aliens to abuse the system.)
EI
"Figures never lie, but liars figure"
Another version I came up with is:
"Numbers don't lie, but liars number*"
*i.e. are numerous
Just credit it to "a person" ;-)
Since when does ordinary, uninsightful, oft-repeated but logically consistent qualify as brilliant?
all we have left to do on our own is decide...what restaurant to go to
Of course not. By then, eating unhealthy foods not prepared in a carbon-neutral kitchen from local organic farms and harvested by workers paid a living wage will be illegal.
Moral imperative? Well no one is stopping you from giving your own money to insure others.
Using the coercive apparatus of the state to impose your values on others is immoral.
Now? Given the usual level of discourse on national health care, this was relatively brilliant.
EI
Yes, extremely brilliant. It's amazing that he managed to find three examples that would help his side of the argument in a completely unbiased manner. From now on I shall advocate no change in any arena based on any kind of numerical evidence because, dammit, liars always figure!
Freddie,
You are making the same unsupported assertion I hear a lot in this debate- "if only people had health insurance, they would cost non-freeriders less than they do today". This goes hand-in-hand with the argument that "we can give healthcare to everyone who doesn't get it today and spend less than we do now".
It is probably perfectly legitimate to write that getting people access to preventative care is better for them, than having a situation where they wait until a problem becomes life-threatening, but I have much doubt that it is actually cheaper for everyone else, on balance.
This is one of the reasons that universal insurance advocates find the going so tough- people with good insurance are very suspicious of promises to cover everyone without, give better care to those with, and have it cost less than before.
"if only people had health insurance, they would cost non-freeriders less than they do today".
I suspect that this is true, if only we could find a way to keep the number of free riders exactly the same as it is today.
The "it'll be cheaper for everyone once we buy it for everyone" argument is probably advanced by those who:
-focus exclusively on revenues at the expense of profit margin
-claim that you should buy their product or donate and write it off on your taxes and you'll be no worse off
-claim that businesses are better off losing money because it will be better for tax purposes
Simply put, these people have no idea how to make money and if they actually have money it is because some one who does know how to make money is using them in a profitable way that has nothing to do with their financial acumen.
"Stan, Where does Prof. Mankiw mention the Democratic presidential contenders?"
He doesn't, and that's one of the problems with his article and with Megan's line of argument. I feel that the presence of large numbers of medically uninsured people is a national problem. It causes unnecessary suffering because people put off seeing a doctor early in the course of a disease for financial reasons, it encumbers emergency rooms with non-emergency cases, it distorts people's choice of employment, and in my personal opinion it's a disgrace. I favor the most conservative possible solution, the Clinton-Edwards-Obama-Massachusetts-Schwarznegger plan. Greg Mankiw and most of the people on this site, including the proprietor, feel there's no problem at all. They point with horror to "nationalized health care", and that's their contribution to the debate. I think this is short-sighted, and it's disillusioning to see people as smart as Megan and Mankiw stick their heads in the sand rather than attempt to come up with a solution.
Can someone point me to a study showing we have excess capacity in our health care system today? People seem to assume that if we take all the health care costs and spread them around to a great pool of participants, "ta-dad! now costs per unit have gone down".
But will we not need to increase consumption of health care? Will that not strain the current system? Will that not require more doctors? Will a shortage of supply in health care coupled with a now increased "entitlement" demand for care cause the price to skyrocket even more so?
it distorts people's choice of employment
I recall reading recently a post by someone who asked if we really wanted to live in a world where people were forced to stay in jobs they hated just for the health insurance.
Yes. We do want to live in that world. It's called "being a grown-up." The need for money to buy food and shelter also "distorts people's choice of employment." Boo-freakin'-hoo. Adults do what they have to do; children whine that they can't do what they want to do.
people put off seeing a doctor early in the course of a disease for financial reasons
People do all sorts of things for financial reasons, such as avoiding buying cars with the latest safety features, taking risky or physically taxing jobs, and forgoing saving for retirement. They weigh the options, decide on their priorities, and choose accordingly. So?
This is not to say that there is no problem whatsoever with our health care system, merely that I am highly suspicious of advocates who suggest that it's wrong to insist that people do what is necessary to secure their own well-being, and the well being of their families.
Setting aside a critique of Mankiw's evaluation of the numbers (the fact that ten million of the uninsured are illegal immigrants makes reform more pressing, not less)
Hardly. We have no obligation to provide anything at all for immigrants, legal or otherwise. If they don't like the health care here they can go back where they came from. The only government with any obligation to provide health coverage for Fnordians is the government of Fnordia. The government of the United States of America has obligations only to Americans citizens.
On the other hand, I don't like the fact that the current tax/legal system makes it much more attractive to get insurance through your employer and discourages buying insurance directly yourself (by making it more expensive). I'd like to see the government neutral on whether you buy insurance yourself or your employer offers it as a benefit.
While it's quite reasonable to have to work to make the money you need to pay for things, it's quite silly to be stuck in a job because of the specific insurance offered when you might be happier and better off in another job, but for the medical insurance when this situation is created by government regulations.
EI
EI: I basically agree re: differential taxation, although another poster on another thread pointed out that pooling people by employer does help reduce the adverse selection problem of a purely private market. That's not a trivial problem to solve.
Hardly. We have no obligation to provide anything at all for immigrants, legal or otherwise. If they don't like the health care here they can go back where they came from. The only government with any obligation to provide health coverage for Fnordians is the government of Fnordia. The government of the United States of America has obligations only to Americans citizens.
If you would approach the question with anything resembling intellectual honesty, you would recognize that the question concerns the fact that Fnordia's government already supplies health care to illegal immigrants, and that reform of Fnordia's health care system might allow them to do it cheaper and more effectively. But apparently that's asking too much of you.
I am highly suspicious of advocates who suggest that it's wrong to insist that people do what is necessary to secure their own well-being, and the well being of their families.
Really? And what if one of the things people did to "secure their own well being" was to vote for candidates who promised to improve the health care situation in a way you didn't approve of? I wonder what your reaction to that would be.
We have no obligation to provide anything at all for immigrants, legal or otherwise. If they don't like the health care here they can go back where they came from. [...] The government of the United States of America has obligations only to Americans [sic] citizens.
Beg to differ, but despite your desire for an All-American fantasy world, legal immigrants have all the rights, privileges & obligations of citizens, w/ the exception of voting & jury duty. Green-card holders, as a matter of fact, would probably be eligible for military service if the draft were reinstated. They certainly were eligible under the previous draft system.
And what if one of the things people did to "secure their own well being" was to vote for candidates who promised to improve the health care situation in a way you didn't approve of?
Well, if they're voting to dip into other people's pockets to pay for their own needs, that doesn't count as "doing what is necessary" secure their own well being. Rather, it is requiring other people to do what is necessary to secure their well being. I would think this distinction to be so elementary as to hardly require clarification.
Children and cats get free rides; the rest of us have to work for a living.
If you would approach the question with anything resembling intellectual honesty, you would recognize that the question concerns the fact that Fnordia's government already supplies health care to illegal immigrants, and that reform of Fnordia's health care system might allow them to do it cheaper and more effectively.
Intellectual honesty tells us that if the government has no obligation to provide those people with care, and is providing them with care anyway, then the "cheap" and "effective" solution is to stop providing them with care. Private entities may continue providing such care if they wish; the market will deal with that problem.
Finding a way to give them care more cheaply is like leaving your doors unlocked so thieves don't damage them when robbing your house -- it only saves you money if you assume that being robbed is a foregone conclusion.
Beg to differ, but despite your desire for an All-American fantasy world, legal immigrants have all the rights, privileges & obligations of citizens, w/ the exception of voting & jury duty.
Don't be banal, Bouffant. "Obligation" obviously referred to the state obligation to provide medical care for its citizens. Immigrants have no present legal right to universal health coverage, and certainly no moral right to such.
Health-care "reform" advocates are bemoaning the fact that ten million immigrants, mostly illegals, are uninsured. So they're uninsured. So what? They can either pay for their own insurance or move to Canada. The point I was making is that we have no obligation to provide them with coverage.
Most proponents of socialized medicine ultimately fall back on the "moral imperitave of minimal care" argument.
I then like to propose an actual "minimal care" system I call the "80's medical plan". You can get health care from the government, but only as of the state-of-the-art in 1980. X-Rays, but no MRIs. Asprin, but no statins or other modern drugs. None of the new cardiac or cancer treatments that have vastly improved survivial rates for these conditions over the last 25 years. Such a system would be quite cheap because (1) contrary to popular belief, the real cost of most specific treatments falls dramatically over time and (2) anyone who could afford something better would not want to be on the government plan.
At that point I usually discover that when the person said "moral imperitave of minimal care" he actually meant "moral imperitave of egalitarian care", which is an altogether different beast. But perhaps Freddie is an exception?
I am thinking that, for a very small investment in manpower, the INS (or whatever it is called today) could station personnel at ERs so that, once an illegal was treated, he or she could receive expedited transport to the border of his or her choice (for a very modest fee, we could also provide transport for his/her immediate family to facilitate family reunification -- elsewhere). That would have an immediate impact on hospital costs and also a direct impact on reducing the number of uninsured...
According to the NYT, we currently spend about 15% of the GNP on health/medical expenses. Is that too much, too little, or just right? For comparison, that compares to about 10% of smaller per capita GNPs in other developed countries.
"It is immoral for a person to lack a certain minimum level of health care because of his or her economic status."
So it is therefore immoral for people to remain in such a low economic status. They need to better themselves so they are no longer immoral. Which they'll do quicker if they aren't given a free ride.
But somehow I don't think that's what Freddie meant.
Freddie wrote: If you would approach the question with anything resembling intellectual honesty, you would recognize that the question concerns the fact that Fnordia's government already supplies health care to illegal immigrants, and that reform of Fnordia's health care system might allow them to do it cheaper and more effectively. But apparently that's asking too much of you.
If it's intellectual honesty you're interested in, be advised that wasn't it, either. Let's try these two very simple questions instead:
1. How is it going to be "cheaper and more effective" to provide illegals with an even better healthcare option than what they have now, especially when that provision adds an additional incentive to cross the border in the first place, thus guaranteeing an even larger stream of illegals seeking said provision?
2. How is this going to be "cheaper and more effective" than, say, competent border enforcement?
1. How is it going to be "cheaper and more effective" to provide illegals with an even better healthcare option than what they have now, especially when that provision adds an additional incentive to cross the border in the first place, thus guaranteeing an even larger stream of illegals seeking said provision?
It is cheaper and more effective than the current system, where emergency rooms becoming defacto doctor's offices for illegal immigrants. Emergency room care is expensive and ill-suited for that purpose. It would be cheaper and more efficient to allow illegals to use the same system as legal citizens, if in fact the kind of universal health care I propose was implemented. And, of course, the "even larger stream of illegals" is a ridiculous canard. They are coming and they are coming by the hundreds of thousands. The notion that some destitute Mexican worker is standing at the border saying "You know, if only I could tap into some American health care system for illegals, I'd cross that border. But as it is... nah."
2. How is this going to be "cheaper and more effective" than, say, competent border enforcement?
"Competent border enforcement" is in fact incredibly difficult and expensive and requires manpower orders of magnitude higher. The only borders of comparable length and physical ruggedness that have been effectively closed in human history have been in places like Soviet Russia or North Korea, where totalitarian systems made it possible to summon the number of troops possible to secure the borders. And, by the way, those places didn't exactly have people dying to get in. We do.
What I find particularly funny about all of you "truth-telling" immigration opponents is that in your advocacy for enforcement only, you are in effect arguing for the status quo. Enforcement alone will not work. It is in the process of not working. We're not going to stop the flow of illegals into this country unless we stop the demand. And we won't stop demand, because powerful corporations have too much ability to control the gears of government. So the question is, do we develop a rational policy that develops some sort of legal status for the 12 million and rising already here? Or do we stick our fingers in our ears and do nothing?
So it is therefore immoral for people to remain in such a low economic status. They need to better themselves so they are no longer immoral. Which they'll do quicker if they aren't given a free ride.
Whatever circumstances have led people to be in a position where they do not have the ability to secure health care on their own, I believe the government should provide it for them. This is a matter of first principle for me. I don't expect anyone else to find my particular moral arguments compelling. But it's the way I feel. I'm unmoved by the notion that people will become less likely to work because their health care is provided for them by the government. But even if they were, I don't care. When people are sick and need help, that care needs to be provided. For me, a basic moral principal.
Intellectual honesty tells us that if the government has no obligation to provide those people with care, and is providing them with care anyway, then the "cheap" and "effective" solution is to stop providing them with care.
If you think that our society would be somehow improved if we allowed illegal immigrants to bleed to death on the floors of emergency room waiting areas, I'm afraid you have such an utter lack of a basic moral compass that constructive conversation with you is impossible.
Freddie: Would you be so kind as to answer my query above? Does my "80's medical plan" satisfy your moral imperative for minimal care? Or is your moral imperative actually a moral imperative for egalitarian care?
Freddie: Would you be so kind as to answer my query above? Does my "80's medical plan" satisfy your moral imperative for minimal care? Or is your moral imperative actually a moral imperative for egalitarian care?
If you'll look upthread, I mention why I use the phrase "minimum level of care".
Yes, I see that you allow that it's okay for rich people to buy better care. I'm trying to figure out what an acceptable minimum is for you. Is the state-of-the-art in 1980 good enough? If so, please say so. If not, please clarify what would constitute a satisfactory minimum.
If you think that our society would be somehow improved if we allowed illegal immigrants to bleed to death on the floors of emergency room waiting areas, I'm afraid you have such an utter lack of a basic moral compass that constructive conversation with you is impossible.
I love how your version of morality involves taking money from me at gunpoint and giving it to the people your heart bleeds for. You've confused coercion with charity, I'm afraid; it takes no morals whatsoever to force somebody else to pay for the things you think are important. That neither I nor my government has any obligation to help a needy illegal immigrant doesn't mean that I feel nothing for the person's need.
But there are around five and a half BILLION people in the world who need better medical care than I can give them, and most of them haven't violated our laws. Society will "be improved", to use your terminology, when people accept their responsibilities instead of trying to invent flimsy rationalizations for why they're entitled to a free ride. Here is the list, in order of responsibility, of the people who need to pay the bleeding man's medical expenses:
(1): The man's insurers
(2): The man himself.
(3): The man's family.
(4): The man's government.
Nowhere on that list is myself or my government. It isn't our problem. Now, if I want to help the man out of charity then good for me -- but he's got no claim on my money, and it isn't the government's place to give out charity to other nations' citizens.
But there's a happy medium here. We can simply sign treaties with other governments, agreeing to provide mutual coverage for their citizens in exchange for full remuneration. In other words, when an illegal Mexican immigrant sucks up $500,000 in medical care here in America, Mexico gets a bill for $500,000. I'm sure you'll agree that's completely fair.
The notion that some destitute Mexican worker is standing at the border saying "You know, if only I could tap into some American health care system for illegals, I'd cross that border. But as it is... nah."
and...
I'm unmoved by the notion that people will become less likely to work because their health care is provided for them by the government.
It's all about marginal effects. A destitute worker might be trying to cross already; a somewhat less destitute worker might be happy where he is until he gets some disease or injury that he can't afford to treat. Similarly, someone with a good job won't quit for the free health care, but someone with a lousy job might. Simply put, people react to incentives.
If you can't accept this reality, then you're so lacking in a basic economic compass that productive conversation is impossible.
And the fact that you don't care if people free ride also suggests that your moral system is different from people like me, who rank personal responsibility rather higher on the list of moral obligations than "caring for those who refuse to care for themselves."
Enforcement alone will not work. It is in the process of not working.
It would be more accurate to say "it is in the process of not being attempted except for token window dressing." But you're certianly right that attacking demand would be more effective.
Whatever circumstances have led people to be in a position where they do not have the ability to secure health care on their own, I believe the government should provide it for them.
I actually agree with this, but I have a very strict defintion of lack of ability that I suspect you wouldn't like.
Mankiw’s argument is thin, and what’s there is of low quality.
To start with, the 47 million includes about 10 million residents who are not American citizens. Many are illegal immigrants. Even if we had national health insurance, they would probably not be covered.
This is false. In the Netherlands, for example, resident aliens are required to purchase health insurance just like anybody else in the country. That insures that if they become ill, they do not end up imposing their health care costs on Dutch taxpayers. One assumes the US will do the same. Resident aliens on a path to citizenship should not spend their first 7 years in the US without health insurance; we end up subsidizing their health care more if they are not insured. As for illegal aliens, Mankiw provides no figures, but that is of a piece with the rest of the US’s problems in formalizing illegal aliens, and must await a general approach to that issue.
The 47 million also includes many who could buy insurance but haven’t. The Census Bureau reports that 18 million of the uninsured have annual household income of more than $50,000
Exactly. Health insurance has become so expensive, and household income is so stagnant, that an increasing number of families are choosing to go without insurance. This is a problem for all of society, as it leads to sicker, shorter, uglier, less intelligent citizens, and costs everyone else money when those citizens fall back on taxpayer-provided health care if they do become ill. Finally, uncertainty of payment when providers treat uninsured patients drives prices up, contributing to rapid health care inflation.
it counts millions of the poor who are eligible for Medicaid but have not yet applied. These individuals, who are healthier, on average, than those who are enrolled, could always apply if they ever needed significant medical care. They are uninsured in name only.
Mankiw ACKNOWLEDGES here that these people are already, in principle, insured by Medicaid. So what possible objection could there be to getting them on the rolls in advance, eliminating uncertainty and saving wasted administrative time?
This is what things look like in the real world. A low-income person shows up in a hospital with an acute problem – a busted lung, a gunshot wound, a diabetic crisis. They have to be treated, but the hospital doesn’t know whether anyone will pay for treatment. So they are treated and billed at a very high rate, because to compensate for risks of non-payment, hospitals jack up the price of private non-insured care. Meanwhile, a hospital administrator and social worker have to be brought in to help the patient apply for Medicaid coverage. Some types of possibly elective care don’t happen while this is being worked out, because of the risk of nonpayment. (The famous example in Sicko is the guy who gets only one of his two fingers reattached.) In the end, either the patient is eligible for Medicaid, and the taxpayer swallows the bill; or the patient isn’t eligible for Medicaid, and…the taxpayer swallows the bill anyway. (If the patient is not low-income, the outcome is that the patient is charged huge prices to compensate for nonpayment by some of the poorer uninsured patients, and may face bankruptcy.)
How would this change under universal health insurance? All low-income people would be pre-enrolled in Medicaid before they get to the hospital, eliminating uncertainty of payment and wiping out the time and money wasted for hospital administrators and social workers to get hospital inpatients enrolled in Medicaid. Lower health care prices, less risk and administrative redundancy, and lower cost to the taxpayer.
Any reform should carefully focus on this group to avoid disrupting the vast majority for whom the system is working.
The system is not working well for most people. That is why two-thirds of Americans think the health care system is broken so badly that it must be completely overhauled, the highest such ratio by far in the developed world. That said, all three Democratic universal health insurance proposals do in fact avoid disrupting anyone’s health plans, leaving all insured Americans with the same providers they have now.
The causes of American obesity are not fully understood, but they involve lifestyle choices we make every day…America’s growing obesity problem is largely attributable to our economy’s ability to supply high-calorie foods cheaply…The rate of teenage motherhood, according to the O’Neill study, is almost three times higher in the United States than it is in Canada. Whatever its merits, a Canadian-style system of national health insurance is unlikely to change the sexual mores of American youth.
This is not true. National health care systems provide a mechanism through which public health priorities become visible and can be addressed, including encouraging safe sex, discouraging promiscuity and early motherhood, and promoting better diet. The US economy’s “ability to supply high-calorie foods cheaply” is greater than other countries’ because we massively subsidize corn syrup, carbohydrates, and meat and dairy. Under our current fragmented health system, no one owns this problem. National health systems make the costs of such problems clearer in the national budget. This is in part why countries with universal health insurance systems, even non-single-payer and mainly private systems (i.e. everywhere but the UK and Canada), have better national programs to address issues like reproductive health and diet, and have much lower rates of STDs, teen pregnancy, abortions, infant mortality and obesity. To a man with a hammer, everything looks like a nail; to a man without a hammer, not even a nail looks like a nail. With respect to public health issues like these, we are a man without a hammer.
Finally, unaffordable health costs, rising from 5 percent of GNP in 1950 to 16 percent today: But increasing expenditures could just as well be a symptom of success…advances in medical technology and growth in incomes…The rationality of this phenomenon is stressed in a recent article by [Charles I. Jones and Robert E. Hall]. They ask, “As we grow older and richer, which is more valuable: a third car, yet another television, more clothing — or an extra year of life?”
But Mankiw has just finished arguing that better health care is not responsible for overall greater longevity! (See above: he says the difference between Canada and the US is mostly due to accidents and homicides, not health care.) WTF? But even taking his argument seriously, universal health insurance advocates don’t compare health spending in the US to health spending in 1950; they compare it to health spending in other advanced societies, which is half to 60% of what we spend, with no loss in longevity. And the problem isn’t that Americans are spending more on health care, but that health care is becoming so expensive that while some of society is spending more on it, the rest of society is unable to afford it – be it in out-of-pocket costs or in insurance premiums multiple times as high as those in the rest of the world. If all Americans were equally rich, there would be nothing wrong with spending our growing wealth increasingly on health care. But the median income of American households FELL from 2000 to 2006 while health insurance premiums rose dramatically. So, yeah, there’s nothing wrong with the current system for the top 20% of US households. It’s the rest of us who are getting into more and more serious trouble.
Incidentally:
I recall reading recently a post by someone who asked if we really wanted to live in a world where people were forced to stay in jobs they hated just for the health insurance. Yes. We do want to live in that world. It's called "being a grown-up."
Rob Lyman appears to believe that the entire populations of Europe, Japan, Canada, Israel -- in short, every advanced country except for the US, are composed of children.
Brooksfoe, that's a misreading of what I said. Having universal health insurance doesn't make you a child. Whining about having to work for your health insurance instead of getting it for "free" makes you a child. It's no different than whining about having to work for food or shelter, like our buddy Ken Ilgunas.
But I do believe that an overlarge welfare state infantilizes citizens.
I don't like the fact that the current tax/legal system makes it much more attractive to get insurance through your employer and discourages buying insurance directly yourself (by making it more expensive). I'd like to see the government neutral on whether you buy insurance yourself or your employer offers it as a benefit.
Herin lies the major problem, IMHO.
Could it be that it's this layer of abstraction & obfuscation that causes people to forget that they are making their own health insurance choices because for most of us, it is done through an employer? And that is why they lack consumer power to effect change?
This seems similar to folks who are excited about getting a tax "refund" from the IRS not realizing that it was their own money to begin with.
Rob, the argument is that every other advanced economy has a health system in which insurance is decoupled from employment, so that you select your job based on how much it pays and how rewarding it is; your health insurance is a separate issue. The US system, with its weird archaic tax break for employer-sponsored health benefits, creates a drag on efficiency by making employment decisions contingent on the irrelevant issue of health insurance. My choice of job shouldn't dictate my choice of health plan, any more than it should dictate my choice of TV or restaurant. That's just a wasteful drag on the market.
Imagine a system where changing jobs would mean losing your access to beef, say, and having to switch to an all-fish diet. This would be a ridiculous distortion of the labor market. It is, in fact, the situation they used to have in the USSR, where people made employment decisions based on access to scarce consumer goods through factory sources; it meant people with mathematics degrees might take jobs at slaughterhouses instead of cybernetics labs, because you can't eat software.
In the current American context, being a grown-up involves making the difficult choice to stay in a worse (and possibly lower-paying) job to keep the health benefits. But there is nothing particularly grown-up about failing to act to improve the insurance overall, so we don't have to make that rather clumsy, pointless and economically inefficient choice. Europeans don't have to make that choice -- not because their health insurance is free (it isn't), but because it's decoupled from employment. To do that, you need to have certain kinds of regulations and government ground-laying institutions. But it's not a less mature system, and it doesn't mean Europeans aren't grown-ups. They are, in fact, grown-ups who have made a very rational collective decision about how to organize their health insurance systems more efficiently than ours.
it doesn't mean Europeans aren't grown-ups.
For the second time, I never said they were.
You make good arguments about decoupling health insurance from employment, which I don't necessarily disagree with, although I don't think the only or the best way to decouple is to go to universal coverage.
But you're repeatedly missing my point. Sometimes grown-ups have to do unpleasant things because they're necessary. This may include working a job you don't like because it offers you something else you need. Some advocates of universal coverage apparenlty don't like this. They are the ones earning my scorn.
I'm a little frightened by this. While it sounds great for everyone to be healthy and eat right and exercise, I don't want the government forcing people to eat right or exercise. I'd be happy to get rid of farm subsidies, but I don't see that happening even if we did have nationalized health insurance/care. I'm not sure how nationalized health care would lead to healthier diets, more exercise, and healthier sexual practices without some pretty intrusive government regulation.
We are already seeing this in the UK and the US with efforts to ban various "unhealthy" food ingredients. Given the primitive state of nutrition, the last thing we need is for well meaning government officials to ban food items. Maybe they'd have calorie taxes to tax high-calorie meals or you'd have to fill out a food tax form indicating your food consumption for the year and then pay a tax if you ate too many calories. Tax deductions based on the number of miles you jog? Fines for unprotected sex? What are we talking about here?
EI
"Many are illegal immigrants. Even if we had national health insurance, they would probably not be covered."
This is false. In the Netherlands, for example, resident aliens are required to purchase health insurance just like anybody else in the country.
That's the most moronic argument I've heard in weeks. Yes, LEGAL immigrants could perhaps be required to buy coverage, if they could afford it, but we're talking about ILLEGAL immigrants. Illegal immigrants can't be required to do anything. They're already required to get the hell out of the country altogether, for example, and that's obviously not working. How will "requiring" them to buy their own health insurance work, exactly?
You didn't read Mankiw's piece, Dan, did you? He stated that non-US citizens would probably not be covered. This is false. Legal resident aliens would in all likelihood be covered. Mankiw has no estimate of how many of his estimated 10 million resident aliens among the 47 million people usually termed uninsured are illegal. In general, there are a lot more legal resident aliens in the US than illegals. Anyway, this is a problem to be resolved by adopting a strategy for formalizing illegal aliens, not a problem of universal health insurance. Next time, before calling an argument "moronic", try and make sure you understand what you've read.
EI, I wrote a long post in response to your point which seems to have been swallowed by the filter, but suffice it to say that countries with universal health systems aren't more likely to ban or fine negative health behaviors. Instead, they have more contact points and tools for influencing popular health behaviors without coercion. In the Netherlands, where every newborn gets a home visit by a doctor or RN a day and then a week after birth, where newborns are automatically scheduled for their one-month and three-month checkups at local clinics, and where a government-certified "crib-carer" is sent to each new mother for a week to help clean up and offer tips on bathing, feeding, etc., there's are obvious entry points for teaching mothers how to breastfeed, communicating hygiene information, detecting health problems early, etc. The more of a comprehensive health system you have, the fewer people fall through the cracks and wind up at emergency rooms getting acute care. When American doctors talk about adopting new public health priorities, there's always a slight undertone of despair: sure, but how do we actually reach the population? We can only reach the ones who come to us. (See, for example, the HIV issue.) European countries have better tools to reach everyone.
Brooksfoe - Re: "Exactly. Health insurance has become so expensive, and household income is so stagnant, that an increasing number of families are choosing to go without insurance. This is a problem for all of society, as it leads to sicker, shorter, uglier, less intelligent citizens"
But the population as a whole is becoming healthier, taller, and if IQ tests are to be believed more intelligent (uglier or better looking is too subjective so I'll ignore it except to say I don't think people are getting uglier)
Re: "and costs everyone else money when those citizens fall back on taxpayer-provided health care if they do become ill."
But probably not as much as it would cost to provide them with regular health care, esp. considering that providing free or cheap health care will increase their demand, and also the demand of others (people moving here legally or illegally to get the free health care, people with insurance dropping insurance because they figure they will get coverage for "free")
You didn't read Mankiw's piece, Dan, did you? He stated that non-US citizens would probably not be covered. This is false.
No, he didn't. The pronoun "they" refers to the subject of the preceding sentence, which was "illegal immigrants", not "immigrants". Back to English class with you.
Mankiw has no estimate of how many of his estimated 10 million resident aliens among the 47 million people usually termed uninsured are illegal.
He didn't cite any, and neither do you -- so you've no support for your claim that Mankiw's statement was "false". If you want to say he didn't provide supporting evidence for the claim that many uninsured aliens are here illegally, fine. THAT statement would be correct. Of course, given that between a third and half of all aliens are here illegally, and given that illegal immigrants have a much harder time getting insurance than legal ones do, quibbling over a failure to cite supporting evidence for the claim that "many" uninsured immigrants are illegals is pretty banal.
Anyway, this is a problem to be resolved by adopting a strategy for formalizing illegal aliens
It isn't a problem at all. So they lack health insurance -- so what? If they don't like mowing lawns with no health care plan they can walk back across the border and petition the government there for coverage.
No, Dan, the referent of "they" in Mankiw's piece is unclear. Since he provides no estimate of the number of illegals in his figure of 10 million non-citizens, it is not clear whether the issue he describes is significant at all. Maybe a lot of the uninsured are serial murderers! But I have no idea how many, so what's the point of bringing it up? A glance at the US Census figures Mankiw's referring to (http://aspe.hhs.gov/health/reports/05/uninsured-cps/index.htm#citizenship) shows that it comes from Current Population Survey data, and the CPS doesn't try to ascertain legal vs. illegal status of respondents. So the question comes down to: how many illegal resident aliens do we think the US Census's Current Population Survey?
The answer is: who knows? On the one hand, illegal immigrants seem extremely unlikely to be willing to talk to Census Bureau surveyors. That would suggest that few among the 78,000 households interviewed by the CPS were likely to be illegal immigrants. On the other hand, the Hispanic population is over-represented among the uninsured (30%), and illegal immigrants are disproportionately Hispanic. So really, who knows?
No, Dan, the referent of "they" in Mankiw's piece is unclear
Well this is progress -- you've gone from expressing absolutely certainty of Mankiw's meaning to admitting that you're not sure what he meant.
But of course it isn't actually unclear, because there are two possibilities and one makes no sense. If "they" refers to the illegals mentioned in the previous sentence then everything in the paragraph fits. If it refers to all 10 million noncitizen uninsured then (a) the mention that many are illegal immigrants is a nonsequiteur and (b) his statement ceases to be self-evidently true. In other words, there were two possible meanings, one in which he concisely stated a simple fact (illegal immigrants are unlikely to be covered by national healthcare plans), and another in which he made a bizarre claim and mentioned illegal immigrants for no reason. You choose the second meaning, because you were looking to pick a fight. Sensible people recognize that the first meaning is the obvious one.
And that's enough about that silliness.
So the question comes down to: how many illegal resident aliens do we think the US Census's Current Population Survey? The answer is: who knows?
Don't act like the US Census is the only source of information on immigrants -- or the only one Mankiw used. The generally accepted estimate used by most government officials and NGOs is that approximately 1/4 to 1/3 of noncitizens in the United States are here illegally, with the proportion rising. As they have both less legal access to medical coverage AND less money than the average legal resident it is fairly obvious that their share of the uninsured non-citizenry will be much higher than that. This fits with other sources, too. For example, according to Dana Goldman's study in Health Affairs, undocumented immigrants accounted for 1/3 of the increase in uninsured adults between 1980 and 2000.
As a resident of France and in the name of all of us living outside the US and covered by single-payer systems, I have to say: thank you, America. Thank you for paying more than you need to, so we can pay less than we should.
Of course I know that the main cause for your 16% and growing health care costs is bloated overheads. But there's also another reason: big pharma recoups its R&D investment in the US, while giving the rest of us a free (well, not quite free, but less expensive) ride.
Thank you once again.
Hans - Some Americans recognize that the US pays more which allows the R&D investment to be recouped in the US. Some argue that we shouldn't do so, because they figure why subsidize France, Canada, Germany etc. Others think well if we don't allow a market price for drugs and instead force the price down, than who will pay enough to cover the R&D.
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